Urology/incontinence

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Expert: Arthur Goldstein, M.D. - 3/16/2015

QuestionQUESTION: I wrote to you back in December. You explained the differences in Urinary Incontinence. This is what my 1st request said: I am a 64 year old female. Recently, suddenly i started with a leaking bladder, or so I think. I went to my GYN as I had a discharge, no bladder problem. first he gave me Metronidazole which did not work, then he gave me a suppository that you used for the nights and I don't have the name of it as he gave me the sample from his office. it seemed to work but that is when this urine leakage started. I went back to the GYN and he said the bladder did not feel like it had dropped but there could be leakage from the urethra. I am waiting on a urine culture at this time but I can actually feel the urine flowing out of me. Can you give me any insite as to what the problem might be? Like I said, this just came about all of a sudden.
You answer was very helpful and after careful thought I decided to go for surgery to correct my problem. Or so I thought. I had surgery this past Monday 3/9/2015. My doctor did a cystoscopy and put a Monarc Urethral sling. I came home with a catheter and packing which was removed on Tuesday. I went back on Thursday as I was very upset and concerned that I was still leaking the same if not worse. He said I have to be patient. That it is only 3 days that the bladder is spasuming and he put me back on meds. I was on vesicare prior to surgery now he put me on Toviaz. To me it sounds like the surgery did not work. Should I be as concerned as I am or should I just be patient as my doctor says? What is your opinion?

ANSWER: Virginia, a urethral sling procedure is used for stress urinary incontinence. The latter is loss of urine with coughing, sneezing, strenuous exercise, etc. In other words, any activity that causes your diaphragm to descend and increase the pressure in your abdomen and then the bladder can cause urinary leakage. Typically, this stress incontinence occurs when the woman has poor vaginal support for her urethra.

The Monarc urethra sling has been around for more than 10 years. Most (but not all) women are continent immediately after surgery. Long term, the procedure is more than 95% successful in normal sized and mildly overweight women but the success rate is about 67% in truly obese women.

The fact that you are leaking 4 days after surgery is somewhat disturbing but it is too soon to determine if the operation was unsuccessful. It takes 6 weeks for the surgical site to heal sufficiently before one can make that type of determination. For the present, there is not much else to do. If you are still leaking in 6 weeks, seek re-evaluation with your surgeon or get a second opinion from another urologist. Good luck.

---------- FOLLOW-UP ----------

QUESTION: Just one other thing so you are aware, I am a tiny person, 5'0" 102 lbs. Up until about a year ago i was a relatively active person. I am in fairly good health, I don't have high blood pressure or high cholesterol. The reason I mention this is that you said the procedure is more than 95% successful in normal sized and mildly overweight women but the success rate is about 67% in truly obese women. I just want an honest observation and if it should have work right away, then before this build scar tissue on it lets remove it and try again if that is what the next step will be because no one should have to be like this. There has to be a next step.

AnswerVirginia, any type of surgery heals with the deposition of scar tissue. In other words, if you decide to have the sling removed now, you will still have scar tissue develop in the area because of the incision and surgical dissection themselves. Scar tissue is not necessarily bad. Sometimes as it forms it may "snug up" the sling and give you the desired result of dryness. Therefore, I would not recommend considering removal of the sling at this point in time.

Female urinary stress incontinence is not my main field of expertise. However, I can tell you that if the operation does not leave you dry after 6-8 weeks post-surgery, you have several alternatives. One would be the injection of liquid "bulking agents" into the submucosal area of the urethra & bladder neck to further compress the sling. This increases the pressure inside the urethra which makes the urethra and bladder neck less susceptible to open during episodes of increased bladder pressure. The other choice would be to had a second operation done in the future.

Again, for the present, I would let the area heal - you might be surprised at the long term result. If you are still leaking after a few months, seek consultation with a urologist who has expertise in this condition. Good luck.

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Comment

Dr Goldstein went above and beyond answering my question to put me at ease. He was very kind and knowledgeable. He should most differently be volunteer of the month.